To determine the cumulative proportion of deaths that occur within three and six months of starting ART, and to identify risk factors associated with early mortality among adults initiating ART in a rural district hospital.

Study Design

This was an observational cohort study.

Setting

The study took place in a main district hospital in Thyolo district, Malawi, from April 2003 to April 2005.

Participants

All adults who were ART-naive and starting treatment in the main district hospital over the two-year study period were enrolled.

Intervention

There was no intervention in this study.

Primary Outcomes

The primary outcome was mortality at three months and six months after initiation of ART.

Results

Complete data were available for 1507 participants (34% male), and the median age was 35 years. At ART initiation, 76% were in WHO stage III, 23% in stage IV, and 1% in WHO stage II but with CD4 count ≤ 200 cells/µL. Fifteen percent had active TB, and all of these were also receiving TB treatment. All enrollees were also taking cotrimoxazole prophylaxis. The median CD4 count was 123 cells/µL, the mean BMI was 19.6 kg/m2, and 36% of those starting ART were malnourished. With 1361 person-years of follow-up, 78% were alive and on ART at the end of the study, 2.5% transferred out, 3% were lost to follow-up, and 3.5% had stopped ART. There were 190 (12.6%) deaths. Of the 190 deaths, 61% occurred in the first three months and 79% within six months. Significant risk factors associated with mortality in the first three months after adjustment were WHO stage IV disease (OR 2.1, CI: 1.4-3.3), CD4 count below 50 cells/µL (OR: 2.2, CI: 1.2-4.0), and increasing grades of malnutrition based on BMI (OR for BMI less than 16.0 kg/m2: 6.0(4.6-12.7). Similar results were found for deaths within six months. The trend of increasing mortality with increasing malnutrition and decreasing CD4 counts for the three-month and six-month follow-up time was significant (p<0.001 for both). Among those who died in the first week, 91% had an active WHO-defined opportunistic infection attributed as the main cause of death, oral recurrent Candida being the most common cause. Sixty-eight percent of those who died in the first three months were malnourished (BMI less than 18.4 kg/m2).

Conclusions

The authors conclude that in a rural district in Malawi, BMI and clinical staging could be important screening tools to identify individuals who, despite initiation of ART, are still at high risk for early mortality.

Quality Rating

Using the Newcastle-Ottawa scoring system to evaluate the quality of this observational study, the selection of cases, ascertainment of exposure and loss to follow-up were all adequate, and overall the study was of good methodological quality. Limitations that the authors note include the inability to always determine the exact cause of death, and the lack of viral load testing to assess response to ART.

In Context

Studies in Malawi and other developing countries have found that 10 to 15% of those on ART die within a median follow-up period of 15 months.(1,2,3) However, factors associated with this early mortality have not been well studied.

Programmatic Implications

While it has not been shown that interventions targeting malnutrition decrease early mortality among those initiating ART, identification and monitoring of patients starting ART with malnutrition may be helpful in avoiding early mortality.